Final Report > Chapter 24: A Health Service which is Well Led > The 1980s and early 1990s - national leadership in relation to the quality of healthcare

The 1980s and early 1990s - national leadership in relation to the quality of healthcare

2 In the decades after the establishment of the NHS (in fact right up until the late 1980s) central government, through the Department of Health (and formerly the Department of Health and Social Security), interpreted its responsibility for the NHS largely in terms of planning and of allocating resources. It did not see itself as being responsible for, and thus accountable for, the quality of clinical care, either in terms of setting standards or of monitoring clinical performance. [1] Quality was regarded by government as a matter for individual healthcare professionals. For their part, healthcare professionals, particularly hospital doctors, had deeply embedded in their culture the notion of professional autonomy, often expressed in the form of `clinical freedom'. This translated as the autonomy of professionals to manage the care and treatment of patients by reference only to what they considered appropriate for the individual patient. This did not mean that healthcare professionals thought of themselves as unaccountable. Rather, they saw their accountability as being to their profession and professional bodies and (to a lesser extent) the hospital as employer.

3 During Phase One of the Inquiry we received evidence from Sir Graham Hart, former Permanent Secretary at the DoH. Looking back to the 1980s he wrote:

`There was a deeply-rooted reserve on the part of the Department - shared by the professions - about Departmental involvement in clinical performance. This was in general seen as the preserve of clinicians individually and, to some extent collectively.' [2]

This `reserve' was reflected throughout the 1980s in the priorities which were set by government for those in charge of local acute hospitals. These priorities, reflected in targets, related only tangentially to the quality of clinical care received by the patient. Financial targets, targets to reduce waiting lists, and targets to increase the numbers of patients to be treated were predominant. These were, after all, the priorities of a Secretary of State answering to those concerned with spending tax revenue. The experience of patients, how well patients were treated, or how effectively, and with what impact on their health, were only at the margins of policy. Unsurprisingly, these issues in turn, did not rank high among the priorities of those who were in charge of hospitals providing acute care.

4 Over time, pressures grew on government to become involved in the quality of clinical care, no doubt reflecting the growth of consumerism generally. But the `deeply-rooted reserve', whereby government and those who led and managed the NHS avoided involvement in issues of clinical quality, still exerted a powerful influence. Medical and later clinical audit were introduced, but very gradually and participation was voluntary. The `Patient's Charter', when it was introduced in 1991, confined itself, in relation to quality of clinical care, to setting limits on waiting times for treatment. The reforms of the NHS in 1991 were partly driven by the view that the discipline of the market would lead to improvements in the quality of care. But the market was imperfect and fragmented. There were few standards. And such information as was generated about the quality of care was not routinely shared. Certainly very little was made public. Purchasers (health authorities and GP fundholders) had few real financial or other levers to bring about improvements in the quality of care, and in reality they had little choice of provider hospital.

5 While government played only a minimal role, those at the centre of the healthcare professions endeavoured to provide a degree of leadership. From the early 1990s onwards, a number of the Royal Colleges and other professional associations began to develop standards for the care of people with certain illnesses and conditions. This represented the translation of the notion of clinical freedom into a sort of collective professional approach. But it was leadership without authority. They had only very limited formal powers. The curious situation existed in which the right to lead in areas of clinical quality was claimed by the Royal Colleges, as a natural extension of clinical freedom, but the authority which ordinarily would accompany such leadership was absent.

6 Thus, as we saw in Section One, when serious concerns about the quality of paediatric cardiac surgical care in Bristol percolated through to the national level, an organisational form of `pass the parcel' was played out. Each organisation which might have been able to do something, passed the problem on, thinking it was some other organisation's or individual's responsibility. Hardly anyone involved had a clear sense of whom they should turn to, what action to take, or whether, indeed, it was their place to take any action. The situation was compounded by the fact that, in any event, there was no reliable way of evaluating the quality of the service, in the sense of outcomes of the care received by patients. This is what happens when national leadership on the issue of the quality of clinical care is weak: that, regrettably, was the way things were at the time.

7 Reference to Bristol allows us to re-emphasise that leadership at a national level, most particularly through the DoH, crucially sets the context within which leaders of trusts at the local level are able to carry out their responsibilities. With hindsight, it is possible to see that the absence, up to the late 1990s, of national leadership from government on the subject of the quality of clinical care had a role to play in the way in which events unfolded in Bristol. The quality of clinical care did not rank highly in the overall management of the NHS. Nor, until the Audit Commission was given a limited remit for the NHS in 1990, were there organisations external to the NHS which commented authoritatively upon matters touching on the quality of healthcare. [3] But we should stress again that this was no conscious abdication of responsibility on the part of successive governments. Rather, it was an aspect of the unstated compact between government and the healthcare professions, particularly the medical profession, which had helped to see the NHS established in the first place.

Footnotes

[1] See also Section One, Chapter 6

[2] WIT 0040 0002 Sir Graham Hart

[3] The Audit Commission's remit with regard to the NHS was to ensure the proper stewardship of public finances and to help those responsible for the NHS to achieve economy, efficiency and effectiveness